Examining the Impact of Non-Resident Births on Systems Limitations in Philadelphia

Obstetrical Care

Cynthia L. Line, Ph.D.Patricia Morris, MPH

Katherine C. Maus, ACSW, LSWPhiladelphia Department of Public Health,

Division of Maternal, Child and Family Health

Background

Year

# of Labor & Delivery Hospitals

# of Resident Births

1997 19 22,038

2007 8 23,476

2008 (September) 7

15,069

(through 9/4/08)

Philadelphia Births, 2003-2007*

22087

21631

22027

22905

23476

21000

22000

23000

24000

2003 2004 2005 2006 2007

Year

Nu

mb

er

of

Bir

ths

99.2

* 2007 Birth data are preliminary

BackgroundBy 2007 multiple processes were underway

- each representing a different part of the obstetrical picture

Gathering qualitative data from consumers

Local healthcare system advocacy

Public health system study

•Women’s access to delivery options might be limited

•Systems planning should occur to mitigate other worries

•Hospitals are operating at/near capacity

Background

There were various conclusions, including:

Gathering qualitative data from consumers

Public Health system study

Local healthcare system advocacy

Background

Limitations of simultaneous multiple processes

– Limited communication– Limited data sharing/analysis– Limited solutions

Background

• The Division of Maternal, Child and Family Health (Philadelphia Health Department) proposed a different process:Upon completion of simultaneous multiple processes, unite under a common purpose to better understand OB capacity and subsequent impacts in Philadelphia

Improving Practice

Mid- 2007 the Philadelphia Department of Public Health convened and hosted a meeting of key stakeholders and decision makers:

Hospital CEO’s

OB Department Chairs

Representatives from the Philadelphia Health Centers

(FQHC and city)

Midwifery community

Health insurers

MCH advocates in the city

Improving PracticePhiladelphia Health Department would share

information from its analysis for systems planning, including the following findings:– Despite hospital closures, there do not appear to be significant

changes in birth outcomes for Philadelphia residents• Including changes in the geographic distribution of existing

hospitals

– System changes have disproportionately impacted certain hospitals

– Total available delivery beds in Philadelphia and nearby suburbs might become inadequate for the number of Philadelphia and suburban births

Improving Practice

Three taskforces were convened and charged with work into 2008:

1. Sentinel Perinatal Health Events2. OB Services for Uninsured and

Undocumented Pregnant Women3. OB Services Reimbursement Taskforce

Each taskforce was co-chaired by a stakeholder and a Health Department staff member

Improving PracticeSome Conclusions:

1. Sentinel Perinatal Health EventsCollect sentinel events metricsImplement data sharing

2. OB Services for Uninsured and Undocumented Pregnant WomenDevelop partnerships and create a forum for planning,

delivery, and monitoring of services

Use ongoing studies of local need and capacity to inform planning

3. OB Services Reimbursement TaskforceImprove access to care, including sharing information, alternative

models of care, research on barriers to care, etc.Advocate for reimbursement of OB care that is adequate to cover

costs

Improving Practice

Recommendations from the floor lead to the creation of three new work groups to continue this work through 2008:

1. Monitoring Sentinel Events

2. Comparison of Costs and Reimbursement

3. Medical Liability Costs and Coverage

Improving Practice

MCFH recognized the ability to plan for OB services in Philadelphia should not be limited to understanding the births of

Philadelphia residents only

• Major city with some of the best hospitals• Major metropolitan area with a large suburban

population

Improving Practice

MCFH Evaluation Unit realized conversations by multiple partners were

based on different realities:

• Some partners were planning based only on Philadelphia city residents

• Some partners were planning based on “all patients” served by systems

Improving Practice

In order to inform planning moving forward, the MCFH Evaluation Unit analyzed city and non-city residents to determine what impact,

if any, non-city residents had on the OB system in Philadelphia

Improving Practice

• Birth record data for 2003-2007 were analyzed.– Data are received from the PA Dept of Health– Data reflect births in Philadelphia hospitals– Data were geocoded to indicate whether

births were to Philadelphia residents or to non-residents

– Data for all years were combined to minimize extreme sample size differences

Improving Practice

Births to non-residents average 3,000-4,000/year while births to residents average

22,000-23,000/year

Improving Practice

Chi-Square analysis compared residents and non-residents on several categorical measures.

Improving Practice

Non-residents were more likely:• To have gestational diabetes &/or gestational

hypertension• Vaginal bleeding and/or perineal lacerations • To have premature rupture of membranes• To have c-sections

Improving Practice

Non-residents were also more likely :• To have babies who are low birth weight and/or of

early gestational age• To have had infertility treatments• Have multiple births greater than twins• Be of advanced maternal age• Have babies requiring NICU admissions

Improving Practice

Philadelphia residents were more likely• To have had a previous pre-term birth• To experience precipitous labor• To have prolonged labor• To be teens

Improving PracticeConclusions• Analysis indicates differing patient needs and

issues for resident and non-resident women

• Differing needs and complications have the potential to impact capacity of OB units differently– E.g. if non-residents have more multiple births

requiring c-sections and NICU admits, the level of care and length of stay is much greater

Improving Practice

Obstetrical planning in Philadelphia should include planning for different populations with different needs as opposed to planning based only on data for resident births

Contact Information

Cynthia Line, Ph.D.

Research/Data Manager

Maternal, Child and Family Health

Philadelphia Department of Public Health

215-685-5264

cynthia.line@phila.gov